Posters Review Surveillance of Patients With NAFLD to Identify HCC


Two posters presented at The Liver Meeting evaluated nonalcoholic fatty liver disease (NAFLD)–associated hepatocellular carcinoma (HCC) to understand the burden and identify the risk for developing HCC.

The prevalence of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States, but it remains unclear to what extent NAFLD contributes to the prevalence of hepatocellular carcinoma (HCC). Two posters presented at The Liver Meeting evaluated NAFLD-associated HCC to understand the burden and identify the risk for developing HCC.

The first poster1 used the Surveillance, Epidemiology, and End Results–Medicare database and analyzed all Medicare beneficiaries with continuous part A and B coverage. The patients included received their HCC diagnosis from 2011 to 2015 and were 68 years and older. NAFLD was defined based on codes for fatty liver, obesity, diabetes, or both dyslipidemia and hypertension but no other known liver diseases.

There were a total of 4388 patients with HCC, and NAFLD accounted for 34.3% of cases. Of patients with NAFLD, 56.0% had cirrhosis compared with 83.7% of patients with other etiologies. More than half (55.0%) of patients with cirrhosis had unrecognized cirrhosis when they received their HCC diagnosis, and patients with NAFLD had a higher likelihood of having unrecognized cirrhosis.

A multivariable analysis found NAFLD was associated with lower odds of receiving HCC surveillance and patients with NAFLD had a lower proportion of early-stage tumors and shorter overall survival compared with other etiologies after adjusting for clinical features and HCC treatment.

“Despite its increasing burden, NAFLD was associated with lower HCC surveillance rates leading to non–early stage at diagnosis and poor survival,” the authors wrote. “Early recognition of at-risk patients with NAFLD is critical to increase surveillance implementation and early detection and thereby improve overall survival.”

In the second poster, the researchers conducted a retrospective cohort study of patients with NAFLD seen in Veterans Affairs (VA) hospitals and clinics.2 They evaluated changes in the Fibrosis-4 (FIB-4) index over time and the risk for NAFLD-associated HCC.

A total of 136,530 patients with NAFLD with FIB-4 scores at baseline were seen at VA hospitals between January 1, 2004, and December 31, 2011, with follow-up through December 31, 2018. Of the total cohort, 377 patients developed incident cases of HCC during the mean 10.8 years of follow-up, with an incidence rate of 0.3 cases per 1000 person years.

HCC risk was higher for all other subgroups compared with 73.1% of patients with NAFLD who were at stable low risk and had low FIB-4 score at both baseline and follow-up. Patients without cirrhosis who had diabetes and a persistently higher FIB-4 score had the highest risk of HCC, at 7.31 cases per 1000 person-years.

Overall, the researchers found patients with NAFLD who transitioned to higher or lower FIB-4 values during the course of the study had a corresponding increase or decrease in risk for developing HCC.

“Integrating serial measurements of noninvasive tests for fibrosis in the current proposed care continuum pathway for patients with NAFLD can increase early HCC detection rates and improve overall outcomes,” they concluded.


1. Karim MS, Singal AG, Kum HC, et al. Clinical characteristics and outcomes of nonalcoholic fatty liver diseases associated hepatocellular carcinoma in the United States. Presented at: The Liver Meeting; November 12-15, 2021; Virtual.

2. Cholankeril G, Kramer J, Yu X, El-Serag H, Kanwal F. Association between longitudinal changes in markers of liver fibrosis and risk for hepatocellular carcinoma in nonalcoholic fatty liver disease. Presented at: The Liver Meeting; November 12-15, 2021; Virtual. Poster 1008.

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